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Allergic Contact Dermatitis Caused by Topical Eye Drops
CORRESPONDENCE Allergic Contact Dermatitis Caused by Topical Eye Drops
that the puncta are occluded and excess drops are absorbed by the tissue. GEORGE L. SPAETH, MD
Philadelphia, Pennsylvania
EDITOR: I WISH TO REPORT AN INTERESTING OBSERVATION THAT I
believe may be of help to others. It relates to decreasing the severity of an allergic contact dermatitis caused by topical eyedrops. Topical medications for treatment of glaucoma can occasionally cause serious contact dermatitis. Recently, three cases have suggested that this irritation can be minimized by using “tissue occlusion,” in which a tissue helps with punctal occlusion. This idea first was suggested by the case of a 60-year-old woman with primary open-angle glaucoma who complained of severe irritation of both eyes. She believed that it was related to her medications, which included brimonidine and latanoprost, which were being used in both eyes. The lower lids were severely erythematous, contracted, and excoriated. The conjunctivas were moderately inflamed. She appeared to have severe contact dermatitis. The lid reaction was thought to be related to the medications, and she was advised to stop her current medications and initiate therapy with dorzolamidetimolol twice a day. However, the patient commented that when she used the eyedrops, they sometimes ran over the lids, and she wondered whether she was using too much of the medication. It was suggested to her that she change the way she instilled the eye drops; rather than occluding her puncta with the thumb and index finger, she was advised to wedge a tissue in the area of the inner canthus of both eyes, holding that tissue firmly in place for 30 seconds to absorb any excess drops. Her medications were not changed. When examined a month later, the lid reaction was still present but was markedly less, and the symptoms were markedly reduced. She was advised to continue using tissue occlusion of the puncta. Six months later, the allergic blepharitis was still present, but it was so slight that it was of no concern and was not causing symptoms. Two other cases of marked allergic blepharitis have shown a marked improvement in the appearance of their lids by following this same practice of tissue occlusion. Very soon after the eyedrops are instilled, a tissue is scrunched up and pressed into the inner canthus firmly so 706
©
2006 BY
How to Measure the Whole Ocular Rigidity? EDITOR: PALLIKARIS AND ASSOCIATES1 DESCRIBE A METHOD BASED
on the infusion of fluid and measurement of pressure in the anterior chamber to derive the ocular rigidity in vivo. They used the similar setup as described previously.2 These publications present the largest number of measurement done in vivo and their method is elegant and precise. However, I am asking myself whether it is really the ocular rigidity they derive from their measurements? As demonstrated by Pavlin and associates3 in vitro, the anatomic relationship between the iris and lens surface has a valve effect, preventing flow from the anterior chamber to the posterior chamber (unless the iris anatomy is modified, for example, by an iridotomy). In the Pallikaris setup, the infusion was done through the anterior chamber at a flow of approximatively 264 l/min, leading to an increase in volume and pressure in the anterior chamber. If there is no flow from the anterior to the posterior chamber, the pressure measured in the anterior chamber is different from the pressure behind the iris-lens valve. Both could be related to the strain propagation in the ocular wall and the posterior displacement of the iris-lens plane, but they are not equal. With this assumption, the value called ocular rigidity is more related to the rigidity of the anterior segment than that of the whole ocular globe. An interesting study that could solve the doubt about the methodology is to compare, with the same setup, the rigidity between patients with or without iridotomy. ELIE M. PITCHON, MD, MSC, FEBO
Lausanne, Switzerland
REFERENCES
1. Pallikaris IG, Kymionis GD, Ginis HS, et al. Ocular rigidity in patients with age-related macular degeneration. Am J Ophthalmol 2006;141:611– 615.
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RIGHTS RESERVED.
0002-9394/06/$32.00
that the puncta are occluded and excess drops are absorbed by the tissue. GEORGE L. SPAETH, MD
Philadelphia, Pennsylvania
EDITOR: I WISH TO REPORT AN INTERESTING OBSERVATION THAT I
believe may be of help to others. It relates to decreasing the severity of an allergic contact dermatitis caused by topical eyedrops. Topical medications for treatment of glaucoma can occasionally cause serious contact dermatitis. Recently, three cases have suggested that this irritation can be minimized by using “tissue occlusion,” in which a tissue helps with punctal occlusion. This idea first was suggested by the case of a 60-year-old woman with primary open-angle glaucoma who complained of severe irritation of both eyes. She believed that it was related to her medications, which included brimonidine and latanoprost, which were being used in both eyes. The lower lids were severely erythematous, contracted, and excoriated. The conjunctivas were moderately inflamed. She appeared to have severe contact dermatitis. The lid reaction was thought to be related to the medications, and she was advised to stop her current medications and initiate therapy with dorzolamidetimolol twice a day. However, the patient commented that when she used the eyedrops, they sometimes ran over the lids, and she wondered whether she was using too much of the medication. It was suggested to her that she change the way she instilled the eye drops; rather than occluding her puncta with the thumb and index finger, she was advised to wedge a tissue in the area of the inner canthus of both eyes, holding that tissue firmly in place for 30 seconds to absorb any excess drops. Her medications were not changed. When examined a month later, the lid reaction was still present but was markedly less, and the symptoms were markedly reduced. She was advised to continue using tissue occlusion of the puncta. Six months later, the allergic blepharitis was still present, but it was so slight that it was of no concern and was not causing symptoms. Two other cases of marked allergic blepharitis have shown a marked improvement in the appearance of their lids by following this same practice of tissue occlusion. Very soon after the eyedrops are instilled, a tissue is scrunched up and pressed into the inner canthus firmly so 706
©
2006 BY
How to Measure the Whole Ocular Rigidity? EDITOR: PALLIKARIS AND ASSOCIATES1 DESCRIBE A METHOD BASED
on the infusion of fluid and measurement of pressure in the anterior chamber to derive the ocular rigidity in vivo. They used the similar setup as described previously.2 These publications present the largest number of measurement done in vivo and their method is elegant and precise. However, I am asking myself whether it is really the ocular rigidity they derive from their measurements? As demonstrated by Pavlin and associates3 in vitro, the anatomic relationship between the iris and lens surface has a valve effect, preventing flow from the anterior chamber to the posterior chamber (unless the iris anatomy is modified, for example, by an iridotomy). In the Pallikaris setup, the infusion was done through the anterior chamber at a flow of approximatively 264 l/min, leading to an increase in volume and pressure in the anterior chamber. If there is no flow from the anterior to the posterior chamber, the pressure measured in the anterior chamber is different from the pressure behind the iris-lens valve. Both could be related to the strain propagation in the ocular wall and the posterior displacement of the iris-lens plane, but they are not equal. With this assumption, the value called ocular rigidity is more related to the rigidity of the anterior segment than that of the whole ocular globe. An interesting study that could solve the doubt about the methodology is to compare, with the same setup, the rigidity between patients with or without iridotomy. ELIE M. PITCHON, MD, MSC, FEBO
Lausanne, Switzerland
REFERENCES
1. Pallikaris IG, Kymionis GD, Ginis HS, et al. Ocular rigidity in patients with age-related macular degeneration. Am J Ophthalmol 2006;141:611– 615.
ELSEVIER INC. ALL
RIGHTS RESERVED.
0002-9394/06/$32.00